Communication With Cognitively Impaired Clients PDF

COMMUNICATION WITH COGNITIVELY-IMPAIRED CLIENTS People with cognitive impairment struggle with poor intellectual functioning and have difficulty communicating and understanding what others are saying to them. Confusion sets in and they can become disoriented to person, place, situation and time. Wh...

COMMUNICATION WITH COGNITIVELY-IMPAIRED CLIENTS People with cognitive impairment struggle with poor intellectual functioning and have difficulty communicating and understanding what others are saying to them. Confusion sets in and they can become disoriented to person, place, situation and time. While each person is unique, those who are cognitively impaired lack organized thought processes and the ability to establish progressive personal goals. Working with a client who has a significant degree of cognitive impairment can be difficult. When caring for someone who is confused, uncooperative, and aggressive, it is important for healthcare workers to recognize the client is doing the best that he/she can. Learning Goals: 1. Identify two possible causes of cognitive impairment. 2. Identify aspects of non-verbal and verbal communication. 3. Identify two key approaches that can be used when working with the client with cognitive impairment. 4. Identify why people with cognitive impairment may act aggressively. 5. Identify the best approach for working with someone who is acting aggressively. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 1 Introduction There are many challenges healthcare workers face and one of the most difficult is working with clients who are cognitively impaired. The word cognitively is derived from the word cognition, and the word cognition means of or relating to, conscious thinking. This is a complex aspect of human health because there is no single condition, illness, or disease that causes cognitive impairment. Cognitive Impairment: An Overview Everything people do in their daily lives may seem simple but all of these actions actually require complex intellectual abilities and tasks. The term "complex intellectual tasks" would seem to be limited to describing activities such as mathematics, solving memory problems, and intricate problem solving but even the most basic human daily tasks require significant, higher intellectual ability. In order to go through a day safely and successfully, people have to be able to reason, to think, and to use logic. They need to be able to communicate, use short-term and long-term memory, and learn new tasks. All of those skills - the ability to reason, use logic, communicate, use short and long-term memory, learn new tasks - involve higher intellectual abilities needed in order to function in a given environment. People with cognitive impairment have limited higher intellectual functioning. They have difficulty communicating, and difficulty understanding what is said to them. They can, at times, become confused about others around them, and they can be confused about their own identity. They can also be confused about where they are, what day of the week it is, and what year it is. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 2 People who suffer from cognitive impairment often do not have the ability to think clearly and logically, or they may only have the ability to do so in limited circumstances or for brief periods of time. Of course, each person is different in terms of strengths and weaknesses. For example, some people may have no difficulty with short-term or long-term memory problems but have considerable difficulty learning new tasks. Causes Of Cognitive Impairment There are many diseases and medical conditions that can result in temporary or permanent cognitive impairment. Although the list of causes is long, the common theme among them is that there has been some damage or compromise to the parts of the brain that control higher intellectual functions; such as, an illness, disease, or accident that has affected parts of the brain that control the ability to think, concentrate, and reason. Although many people with cognitive impairment are elderly, being old does not always mean that someone has a diminished mental capacity. It should never be assumed that simply because someone is old that being agitated or confused is usual for their age. People with cognitive impairment may have had a stroke, they may be suffering from Alzheimer's disease, or they may have had a head injury. In some instances, the cause is unknown. Regardless of why individuals have cognitive impairment, coping with this situation can be very difficult. It takes patience and compassion. Above all, healthcare workers must remember that individuals with cognitive impairment do not have the ability to function and think as others with normal functioning. Normally, people use powers of thought, concentration, memory, logic, cnaZone.com cnaZone.com cnaZone.com cnaZone.com 3 and language to cope with their environment. For cognitively impaired people, those skills are absent or damaged. As a result, they cannot understand what they see and hear or how others are communicating. Many times, this will leave them frightened and confused and, more importantly, it leaves them dependent on others. As mentioned above, there are many possible causes of cognitive impairment. The majority of cases of cognitive impairment, however, are due to a few, relatively common issues. These issues may lead to temporary or permanent impairment. Permanent causes of cognitive impairment can include: • Alzheimer's disease • Brain tumor • Cerebrovascular accident (CVA), which is commonly called a stroke. A stroke is cause by bleeding in the brain or by a clot that lodges in a blood vessel in the brain. In either case, there can be permanent damage to the brain. • Chronic drug use, i.e., chronic use of alcohol, amphetamine, or other illicit substances • Traumatic brain injury Temporary causes of cognitive impairment include: • Dehydration • Fever • Intoxication with alcohol or drugs • Hypoglycemia (a.k.a., low blood sugar) • Hypotension • Hypoxia (low oxygen content in the blood) cnaZone.com cnaZone.com cnaZone.com cnaZone.com 4 • Infections • Medication side effects • Transient ischemic attack (TIA), which is similar to a stroke but the damage is not permanent. • Withdrawal from alcohol or drugs The permanent causes of cognitive impairment listed above cause death to the brain cells by several different mechanisms. They completely block blood flow to the brain, there is traumatic damage to the brain, or they cause damage to the brain by interfering with normal metabolism of the brain. Many of the temporary causes of cognitive impairment disrupt the higher intellectual abilities because they interfere with the metabolism of the brain. The brain needs oxygen and food - the food being glucose, or blood sugar - to operate, and the brain and the central nervous system are extremely sensitive to a lack of oxygen or glucose. Without adequate supplies of these nutrients, some level of cognitive impairment will be seen. Elderly people are especially at risk because may have frail health and pre-existing medical conditions and without glucose and oxygen cognitive abilities will suffer. It is important to remember that although cognitive impairment is more common in the elderly, this is simply because many of the causes of cognitive impairment such as Alzheimer's disease, stroke, and TIA are more often seen in the elderly population. Getting older does not mean that mental function will also decline to a point that the elderly person cannot competently perform activities of daily living. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 5 Example: An 89-year-old client who has a fever of 104.3°F also has an increased heart rate because of the fever. The client’s heart rate increases as body temperature goes up. If the patient has a high fever with a rapid heart rate, and the heart is too weak to tolerate the faster pulse, or pump an adequate blood supply with each heartbeat, the brain will not get the blood and oxygen it needs and the client will become confused. It should never be assumed that a sudden decrease in someone's mental abilities is acceptable just because that person seems to be of an age where mental abilities are assumed to decline. The decrease in mental acuity may be from a simple, easily treatable cause or it may indicate that a serious medical condition has developed or is developing. Cognitive Impairment Case Example This scenario involves a CNA who returns home after a long day of work. The CNA is due to work tomorrow at 7:00 a.m., so the alarm is set for 6:00 a.m. Imagine that you are the CNA in this scenario. You are awaked from a deep sleep because someone has just turned on the lights, and there are two women standing in the bedroom that have never been seen before. You have no idea who they are and before having a chance to become oriented to the situation, one of cnaZone.com cnaZone.com cnaZone.com cnaZone.com 6 them yanks the covers off the bed and the other one is trying to remove your pajamas. They are saying something about how it is time to get up and get washed, but it is difficult to understand what they are saying. The only thing that matters in the moment is that you were sleeping and now two strangers are trying to undress you. Suddenly, a third person comes into the room. That person, without a word, pulls up one sleeve of your pajama top and sticks a needle into your arm and then tries to push some pills into your mouth. Then, they all team up and try and pull you out of bed. They are not necessarily being rough, but it is obvious that they are in a hurry. How would you react if someone you did not recognize woke you up from a deep sleep, tried to take your clothes off, stuck a needle into your arm, was pushing pills into your mouth, and trying to yank you out of bed - all while speaking what was essentially a foreign language? It is safe to say that you would be very frightened and confused. It would not be unreasonable for you to resist and you might even try and defend yourself as best you could. This illustration may seem extreme but it is not an unusual occurrence. Anyone who has worked with individuals who suffer from cognitive impairment will recognize this scenario as very common. A patient who has a significant degree of cognitive impairment will be unable to understand what is happening and the confusion and difficulty in communicating with these individuals can be quite frustrating for the patient and the people caring for the patient. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 7 Working with a patient who has a significant degree of cognitive impairment can often be very difficult. What is considered to be normal patterns of communication are not possible. However, it is important to realize that these interactions are a two-way street; the situation is difficult for the client, as well. When caring for someone who is confused, uncooperative, perhaps even aggressive because that person does not have the ability to understand what is being said or done around them, it is absolutely natural to feel frustrated. But it should be remembered that the client is doing the best he/she can and their feelings of confusion and fear are probably just as intense as your feelings of frustration. Someone with a significant degree of cognitive impairment may not know why he/she cannot understand the world around them. This person often does know on some level that there is impairment. He/she can sense that the ability to cope is limited and as a result, fear and uncertainty are natural feelings when interacting with others. Persons with cognitive impairment feel a bit defenseless, and they are a bit defenseless. They are impaired, they sense that they are impaired, and that increases their anxiety level. Caring For Patients With Cognitive Impairment Fortunately, with the proper attitude and some simple techniques, working with individuals who have cognitive impairment does not have to be painful for the caregiver or for them. Some basic tools that can help healthcare workers when working with a cognitively impaired individual are discussed here. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 8 Patience Those caring for cognitively impaired individuals will need a lot of patience. The natural instinct when interacting with another adult is to assume that he/she is at the same level of emotional and intellectual ability as the average person. This is not true of those with cognitive impairment. This is a simple idea to understand, but many people have difficulty remembering this. It may help to consider how it was like interacting with a small child. A child would not be expected to act like an adult, or expected to understand complex ideas or new and unusual situations. Knowing all of this, adjustments are made in how one would communicate and treat the child and the responsibility for making these adjustments would fall on the adult. When working with a patient who has cognitive impairment, in one sense, the healthcare worker or caregiver is acting as the adult in that relationship. Patience would be needed. The above example is not intended to compare an adult to a child or to be demeaning. It is simply used to stress the point that expectations must be realistic. The CNA may be working with clients who have a significant disadvantage in terms of their mental abilities. Non-verbal Communication Most individuals think of communication as what is expressed or the words used but there is quite a bit of communication that is nonverbal, such as the tone of a person’s voice, the loudness or softness of speech, the speed at which a person talks, the way a person stands, and where a person stands when speaking to someone else. These are forms of non-verbal communication. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 9 People with cognitive impairment may have lost the ability on an intellectual level to understand everything others are saying but their other senses are completely intact. They will often respond to how others speak to them rather than what they are saying, so it is often best for those speaking to a cognitively impaired person to stand where the person can easily see and make eye contact with others. Healthcare workers should avoid touching the cognitively impaired person until sure that he/she will not feel threatened by physical contact. They should never pull or yank on someone if wanting that person to move, change positions, stand up, etc. When first approaching someone, it’s important to try and do so slowly and to not rush at them. Verbal Communication The ability of an impaired person to communicate verbally can be varied and change. Throughout interacting with a patient, the CNA may have to adjust his/her communication approach while observing changes in the patient’s cognitive abilities. Some general tools and approaches will help. It helps to keep communication simple and direct. The healthcare worker should be gentle and take time when communicating to these patients, speak slowly and clearly. Language should be kept at a basic level. This does not mean those caring for people with a cognitive impairment should be "talking down" to them but, rather, should give them the time they need to process what is being said. It’s important to try to remember that it may take them far longer than one could imagine to completely cnaZone.com cnaZone.com cnaZone.com cnaZone.com 10 grasp the meaning of what others are saying. Repetition and reinforcement will also help cognitively impaired patients to remember. When dealing with the cognitively impaired person, it’s also important to not speak quickly, and to make sure that simple terms and words are being used. The healthcare worker should not be afraid to repeat what he/she has said, and should not be surprised or frustrated when having to repeat statements several times to the patient. The CNA caring for the cognitively impaired patient should not forget that although the patient may remember something that was said earlier in the day or week, these patients may forget something that was said to them just an hour or a few minutes before. It takes everyone time to get used to a new idea. Change is not easy for anyone but for the person with cognitive impairment even ordinary situations in day-to-day life can represent new ideas and change. While most people can recognize others and situations that they are familiar with, many times for the cognitively impaired person, even people and places they should know well may seem strange and unknown. They are constantly challenged by a world that seems new and different from moment to moment. Imagine how difficult it must be to constantly be "re-introduced" to the world around you. Flexibility Perhaps nothing is more important when working with a patient who has cognitive impairment than flexibility. The opposite is also true; nothing is more harmful when working with these patients than being cnaZone.com cnaZone.com cnaZone.com cnaZone.com 11 stubborn or rigid. What is meant when using the term flexible? It means simply that an individual will adjust to the demands of a situation. For the healthcare worker, it means there is the able to change plans and to realize what is or is not important. Getting a task done is far more important than how the task is done. Priority Setting Many healthcare workers see their job as a series of tasks that need to be accomplished. That is true in one sense, but working with people is very complex. Many times, it is simply not possible to do everything needed or that one desires to do, as well as how and when to do a task. Situations change and people change. When an individual is not able to clearly see what, at any given time, is the most important priority, a job will become very difficult. It’s important to know how to set priorities and how to change them as needed. Any experienced health professional will concede that in order to function efficiently, it is important to know what is most important. But it is also necessary to show an ability to recognize when a situation has changed and to understand that a new, more important priority has replaced the previous one. Setting priorities is important, but so is being able to change and adjust priorities. Regular Routines Because the person with cognitive impairment has difficulty remembering people, places, and situations, he/she can be helped by establishing reliable routines. If it is possible, the same CNA should work with the same patients and to try and develop a routine for daily cnaZone.com cnaZone.com cnaZone.com cnaZone.com 12 activities that is simple, does not change, and will be easy for the patient to remember. The CNA should be careful to slowly introduce changes into the patient's daily routine, and to try and explain these changes as clearly as possible. After telling the patient what is going to be done, the CNA should make sure to follow through on his/her promise. The patient may surprise others by remembering what was said, for example, “I will be in your room at 9 in the morning to help them get dressed”, and may become disoriented if promises are not kept. Verbal and Non-Verbal Communication: Example 1 As a CNA, you are caring for a patient who is being treated by the physical therapy department because she is recovering from a broken hip. You need to help the client perform range of motion exercises. These typically take about 10 minutes to perform, there are five separate exercises, and three of them are a bit complicated. You are familiar with the exercises - you have helped other clients do them but this is the first day you have worked with this person. The first three exercises go smoothly, but not the fourth. This one requires you to place your hands under the client's heel and on the sole of the foot. The client must lift her leg from the hip, bend the knee down, and then push against your hand while flexing the leg at the hip and knee. But every time you ask the client to push against your hand she pulls back instead, and at times she straightens her leg instead of bending at the knee. The client has a degree of cognitive impairment because she suffered a stroke, and the simple instructions you are giving her (which seem simple to you) are not working; i.e., "Bend at the knee cnaZone.com cnaZone.com cnaZone.com cnaZone.com 13 and hip, now push, push against my hand." The client cannot seem to understand these simple instructions. The wrong way to handle the situation would be to become impatient. A feeling of impatience would be perfectly normal, and impatience does not imply being rude or discourteous. People who feel impatient may express this by repeating the same instructions in the same way, speaking a little louder and a bit more slowly, and eventually becoming exasperated and frustrated. This approach is rigid and is unlikely to be successful. If the patient cannot understand the instructions for the exercise, giving the instructions over and over again while speaking more loudly and a bit more slowly is not likely to work. The right way to make this experience better for the patient and for you - or at least a better way - would be to see that simplifying the instructions would be difficult as they are very basic. However, you could break them down into small steps in order to give the patient time and you can use non-verbal communication. Instead of saying "Bend at the knee and hip, now push, push against my hand", take the patient's leg and bend it at the hip and while doing so say "Bend at the hip." Repeat this several times, and after each attempt wait a bit to give the patient time to absorb the information, ask her if she understands and then try the next steps. Doing it this way uses simple, short verbal communication and non-verbal communication, small discrete steps instead of a long chain of tasks, and it also makes the process shorter and more manageable. Regular Routines: Example 2 People who have cognitive impairment have difficulty learning new tasks and adjusting to change. Unfortunately, the routines of many cnaZone.com cnaZone.com cnaZone.com cnaZone.com 14 healthcare facilities are often disrupted and unpredictable. As the CNA, suppose you have established a routine for one of your patient's meals and it seems to be successful. His meals are served at the same time every day and he always eats alone. However, on this day not only is the meal 10 minutes late, but because of new admissions to the unit the patient has to take his meal in a different area and eat alongside several other people. It is clear that these changes have upset him, he is confused, and you are worried that he will become agitated. The wrong way to handle the situation would be to fail to recognize how upsetting this change is for this patient who has cognitive impairment (he has suffered a traumatic brain injury), and this would be easy to do. After all, 10 minutes is not a long time and what is so difficult about sitting next to someone else during a meal? So, you tell him that the meal was late but that won't happen again, and that the seating and eating arrangement is temporary; he will be able to resume his normal routine tomorrow. However, that attitude assumes that the patient can easily adapt to and understand changes in the environment and routine, and he is clearly indicating that he can't. That attitude also suggests to the patient that his feelings are unrealistic and unimportant. The right way to handle the situation would be to recognize that all of these changes in the routine have made the patient very upset, and his feelings are normal and should be respected. So your communication, verbal and non-verbal, should focus on providing reassurance, comfort, and support. Direct the patient's attention to the parts of the environment that are part of the regular routine. Talk to him about the food, about what you and he have done together so far that day, and what is planned for after lunch. Distraction can be a very cnaZone.com cnaZone.com cnaZone.com cnaZone.com 15 useful technique for helping calm someone who is upset, and in this situation the distraction will hopefully remind the patient less of how his routine has been disrupted and more of how much of it has been maintained. Encourage him to talk and express his concerns, and be flexible. You may have duties, but try to rearrange your schedule so that you can spend enough time with the patient in order for him to feel safe. Priority Setting: Example 3 Imagine that you are the CNA needing to assist a patient in getting out of bed and getting dressed. You are very busy and you have a lot of other things you need to do for other patients, as well. But the patient you are working with is resisting all of your efforts. He doesn't want to get up, and he does not want to get dressed. You cannot understand why and he cannot tell you. Some people may try to physically lift the patient out of bed and begin to undress him. This is the wrong way to handle this situation. Do not try and force the issue. You can raise your voice slightly, speak firmly but politely, and tell the patient that he has to get up and get dressed now. This would be a normal reaction to the situation; after all, this task does need to be accomplished and you do have a lot of other people to care for. However, trying this approach, the client begins to get agitated and confused. The right way to proceed would be to stop and assess the situation. You need to determine what the most important priority is, and what the best way to accomplish that goal is. Perhaps in this situation you have more time than you think. You might be able to sit quietly with this person for a bit and give him a few minutes in which to adjust. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 16 Ask him why he does not want to get up and get dressed, and give him time to answer; he may not be able to express his thoughts immediately but with a few minutes the reason might be clear. Perhaps you can accomplish the task in steps; this will also give the patient time to adjust. Also, you might be able to move to another task with another patient. It may not be important that the patient get dressed right at that time you had planned. When the day is not going as you have planned, ask yourself: Can you change your priorities to make your day and the patients' day run a bit smoother? Flexibility: Example 4 Flexibility is closely aligned with patience, priority setting, regular routines, and skillful use of verbal and non-verbal communication. Flexibility could be considered to be the essential ingredient to successfully working with a patient who has cognitive impairment. In Example #1 the CNA broke out of her standard routine for performing the range of motion exercises and used new patterns of communication. In example #2 the CNA was able to see the situation from the patient's perspective and also to help him adjust to a change. And in example #3 the CNA was able to see that he had more time than he imagined and was able to think of several different approaches to the problem. All of these examples have implied that the client's cognitive impairment is a permanent condition. However, when the CNA is working with a patient who has become agitated, confused, or uncooperative, he/she must always keep two points in mind. First, is this behavior new and unusual? If the answer is yes, then the CNA cnaZone.com cnaZone.com cnaZone.com cnaZone.com 17 should immediately notify a supervisor. The behavior may simply be an extension of a pre-existing problem, but it could also represent something new. And second, the CNA should keep in mind the possibility that this behavior could be due to a medical problem. In example #3 the patient's agitation and confusion could be explained by a pre-existing cognitive impairment, but the patient could have diabetes and be hypoglycemic. Many times, people who have some condition that caused cognitive impairment, a condition such as a stroke, may well have a medical condition that can affect behavior. Working With Aggressive Patients Most people are able to stop, sit back, and assess a new situation. People can generally decide if they like what they see and whether or not it is safe. If a person is not comfortable, he/she can simply avoid a situation. As experience in the world is gained, this process becomes easier because a person may have encountered similar situations before, and the learning process has become more efficient. Patients with cognitive impairment are not able to stop, sit back, and assess a new situation. Because of their impairment, many situations even ones they have encountered many times before - can seem new. Like everyone else, this can make them anxious, but unlike most people, they cannot draw on their past experiences to interpret what is happening now and they cannot quickly assess what is happening because of their impairment. Not surprisingly, when someone who has a significant level of cognitive impairment is confronted with a new and unusual situation they feel vulnerable and afraid. Unfortunately, in many cases this fear leads to aggression and attempts at self-defense. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 18 It can be very difficult to work with someone who is confused and aggressive. The CNA will need to keep that person safe, but must also protect his- or herself and others. Working with a patient who is aggressive, confused, and potentially violent is very difficult but with some common sense and planning these situations can be handled safely. Do Not Indiscriminately Use Force Using force can often backfire. Certainly, there are times when a healthcare worker will need to physically restrain someone. But when and how to do so should be clearly outlined in the policies of the healthcare facility or employer, and the use of physical restraint is usually only allowed if it has been ordered or approved by a physician or a supervisor. So, the CNA should make sure to become familiar with the rules governing the use of physical restraints before these incidents happen. Physically restraining someone is the last resort. It can be dangerous for the healthcare worker and the patient. Stay Calm It is natural to become excited when someone is acting aggressively. But many times, if allowing that person to express anger the possibility of physical violence can be avoided. Most people have a natural aversion to harming another person, so give the person who is angry the opportunity to be verbal rather than physical. Do Not Take It Personally The patient who is acting aggressively is not doing so because the patient wants to harm another person; the situation is not personal. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 19 Although the patient is acting dangerously, that person believes that he/she is trying to protect herself/himself from others. The CNA should avoid giving them another reason to feel threatened. The CNA should remain quiet, rational, and calm, while remembering that the situation itself is not rational, so trying to force the patient to "see things sensibly" often will not work. The CNA should certainly try and speak calmly and rationally, but a patient who has cognitive impairment and is acting aggressively will be unlikely to be influenced by appeals to reason and common sense. Summary Cognitive impairment is defined as a loss of higher intellectual function; i.e., the inability to perform complex intellectual tasks. It can be temporary or permanent, and there are many causes; Alzheimer's disease, hypoglycemia, stroke, and traumatic brain injury are some of the more common ones. Cognitive impairment is more common in the elderly, but it is should never be considered a normal, inevitable part of aging; it represents a serious pathology. People who have cognitive impairment have difficulty with many of the higher intellectual functions such as short-term and long-term memory problems, adjusting to changes in routine, learning new tasks, or communication. Working with patients who have a significant degree of cognitive impairment is very challenging. But it does not have to be difficult or frustrating for the CNA practicing qualities of flexibility, good verbal and non-verbal communication patience, priority setting, and regular routines. cnaZone.com cnaZone.com cnaZone.com cnaZone.com 20